HCP Uganda

Transcription

1 HCP Uganda

2 For further information: Johns Hopkins Bloomberg School of Public Health Plot 15 Binayomba Ave. P.O. Box 3495 Kampala, Uganda Tel: / 183 Web: Johns Hopkins Bloomberg School of Public Health 111 Market Place, Suite 310 Baltimore, Maryland Office: / Fax: Web: Photographs by Tine Frank, Kim Burns Case, Masturah Chemisto and HCP staff Captions for cover photos: In the top photo, a peer educator counsels a couple on safe male circumsicion in Busia. In the photo on the bottom left, a radio presenter in Soroti shares his experiences with health broadcasting. An HIV positive mother in Mpigi listened to the communication about how to prevent transmitting HIV to her child; her daughter is HIV negative. 2 The HCP Project Final Report July

3 The Health Communication Partnership Uganda Final Report May 2012

4 Acknowledgements A measure of the Health Communication Parternship (HCP) Uganda s success has been the wide network of partners the project has formed and the dedication of each partner towards furthering the project s aims of a healthier population in Uganda. HCP Uganda wishes to especially express its gratitude to the United States Agency for International Development (USAID) for its financial support and to the Government of Uganda for its leadership. HCP wishes to express its gratitude for the contributions of the following partners: Government Partners Ministry of Health (MOH) Uganda AIDS Commission (UAC) Ministry of Education and Sports Ministry of Gender Labour and Social Development Ministry of Justice Institutional Partners AIDS Information Centre (AIC) Communication for Development Foundation Uganda (CDFU) Makerere University School of Public Health (MUSPH) Media for Development International (MFDI) Regional Centre for Quality Health Care (RCQHC) Uganda Health Communication Alliance (UHCA) Implementing Partners African Medical Research Foundation (AMREF) AAfrican Network for Care of Children Affected by HIV/AIDS (ANNECA) Baylor Uganda Clinton HIV/AIDS Initiative (CHAI) Conservation Through Public Health DELIVER Project Department of Paediatrics, Makerere University College of Health Sciences Elizabeth Glazier Pediatric AIDS Foundation Family Health International (FHI-360) Health Initiatives for the Private Sector (HIPS) Project Hope After Rape Infectious Diseases Institute (IDI) Inter Religious Council of Uganda (IRCU) Joint Clinical Research Centre (JCRC) Makerere University John Hopkins University Collaboration (MUJHU) Makerere University Walter Reed Project Malaria Consortium Mango Tree, Ltd. Marie Stopes Uganda Mildmay Uganda Minnesota International Health Volunteers Mulago - Mbarara Joint AIDS Program (MJAP) Mulago National Referral Hospital National Community of Women Living with HIV/ AIDS in Uganda (NACWOLA) National Forum of People Living with HIV/AIDS Network in Uganda (NAFOPHANU) Naguru Teenage Centre Northern Uganda Malaria, AIDS and Tuberculosis Program (NUMAT) Norwegian Refugee Council Pathfinder International Plan International Population Secretariat Private Sector Foundation Uganda (PSFU) Program for Accessible Health, Communication and Education (PACE) Protecting Families Against HIV/AIDS (PREFA) Raising Voices Rakai Health Services Program Reach Out Mbuya Reproductive Health Uganda (RHU) Restless Uganda Saatchi & Saatchi Save the Children Uganda ScanAd Uganda, Ltd. Support to the Health Sector Strategic Plan Project II (SHSSPPII) Supporting Public Sector Workplaces to Expand Action and Responses Against HIV/AIDS (SPEAR) Project Straight Talk Foundation (STF) Strengthening TB and HIV&AIDS Responses in East Central Uganda (STAR EC) Strengthening TB and HIV & AIDS Response in Eastern Uganda (STAR E) Strengthening TB and HIV & AIDS Response in South Western Uganda (STAR SW) Strengthening Uganda s Systems for Treating AIDS Nationally (SUSTAIN) STRIDES for Family Health Project The AIDS Support Organisation (TASO) The Hunger Project Traditional and Modern Health Practitioners Together Against AIDS and other diseases (THETA) Uganda Cares Uganda Health Marketing Group (UHMG) Uganda Network for Young Positives Uganda Private Midwives Association Uganda Red Cross Society Uganda Water and Sanitation NGO Network United Nations Children s Fund (UNICEF) United Nations Population Fund (UNFPA) University of Maryland School of Medicine, Institute of Human Virology World Health Organization (WHO) World Vision Uganda ZOA Refugee Care

5 Contents Introducing HCP 6 Strategising for Social and Behaviour Change Communication 7 Integrating Health Communication: A Sustainable Approach 13 Promoting Family Planning 18 Empowering Young People to Make Healthier Choices 24 Preventing HIV Within Couples 31 Supporting People Living with HIV to Stay Healthy 38 Reducing the Burden of Malaria and TB 45 Strengthening Health Communication Capacity 49 Conclusion and Recommendations 56 A nurse in Bugiri reviews the radio diaries discussion guide as part of the pre-test of the materials.

6 Introduction Between 2007 and 2012, the United States Agency for International Development (USAID) funded the Health Communication Partnership (HCP) project to develop and implement communication strategies and strengthen capacity in social and behavior change communication (SBCC) for improved health in Uganda. Managed by The Johns Hopkins Bloomberg School of Public Health Center for Communication Programs (JHU CCP), this project extended and expanded communication activities initiated between 2004 and 2007 under a previous USAID award. In support of the shared goals of promoting health and improved quality of life, HCP worked hand-inhand with the Government of Uganda and USAID to provide national level strategic and evidence-based communication support in three intermediate result areas: IR 1: Improving the ability and motivation of Ugandans to use services and practices that enhance health; IR 2: Fostering supportive social environments to enable positive health behaviour; and IR 3: Strengthening capacity for sustained health communication. HCP focused primarily on HIV prevention, care, treatment, and support; sexual and reproductive health of young people; family planning; malaria; TB; and capacity strengthening. Where possible, HCP incorporated proven strategies, based on lessons learned by similar programs in Uganda and elsewhere, and combined them with fresh and creative approaches designed to educate, engage, entertain, stimulate, and motivate audiences at national and community levels. Over the years, HCP has worked closely with the Ministry of Health (MOH), Uganda AIDS Commission (UAC), national NGOs, district-based implementing partners, and community based organizations. It is HCP s intention to leave behind skills and resources that will allow its various partners to continue the great work they have been doing in the area of health communication. To this end, HCP has produced a set of electronic toolkits, accessible through the internet at that contain all the materials and resources developed over its five-year existence. This report explains the theoretical framework and approaches that guided HCP. It describes the rationale, interventions and key results for HCP s interventions from , and highlights communication innovations and promising practices for partners to adopt in the following areas: Strategising for social and behaviour change communication Integrating health messages: A sustainable approach Promoting family planning Empowering young people to make healthier choices Preventing HIV within couples Supporting people living with HIV to live healthy lives Reducing the burden of malaria and TB The report also includes voices of people who have worked with HCP to design and implement these interventions and those who have benefited from the programme. HCP have made a very big impact in the area of communication. They have improved awareness and uptake of services and created a change in attitude. We appreciate what HCP has done; they have been a true partner, consulting and sharing throughout. We have enjoyed working with them. - Dr. Paul Kagwa, MOH 6 The HCP Project Final Report July

7 Strategising for SBCC Conceptual Framework The Pathways to Community Health model was the conceptual framework underlying HCP. This model identifies four communication domains: engage individuals, stimulate community dialogue and action, create an enabling environment, and make services more user-friendly. According to this model, strategic communication interventions that address barriers in these domains will result in positive changes in individual behaviour and social norms, more supportive environments, and strengthened institutional and service system capacity; these, in turn, will contribute to improved health. P-Process for Strategic Health Communication Strategic communication is developing clearly defined, multi-channel strategies using a systematic, theory and results driven, analytical process following the steps outlined in JHU CCP s P-Process: 1. Situational assessment and audience analysis; 2. Strategic design with defined audiences, objectives, communication channels, behavior models or theories and implementation and M&E plans; 3. Development and testing of materials, tools, and approaches with intended audiences and stakeholders; 4. Implementation and monitoring of interventions, including production of materials, training, etc.; and 5. Evaluation and re-planning based on evaluation results, and in partnership with key stakeholders. Strategic Approaches HCP employed seven strategic approaches: 1: Help make services more client-centered Knowing that services that are client-centered will better meet client needs, HCP integrated a client empowerment approach throughout its training of health workers and development of job aids and client education materials. The HCP Project Final Report July

8 2: Promote and direct clients to services Although services may be available, people may not think that they need the services, or they may not know where the services are available. HCP worked with MOH, UAC, and implementing partners to identify priorities so that eleven major multi-channel campaigns could be designed and implemented aimed at encouraging the increased use of services by clients most in need of them. To help clients locate services as well as to help health workers and counsellors on the National Health Hotline to provide referrals, HCP assisted the MOH to label health services, map their locations and prepare directories. HCP designed edutainment activities on radio, in comic books and through community drama that included having the characters model the desired behavior of seeking health services. 3: Focus on underlying social issues that influence health behavior In order to support the adoption of new practices, HCP campaigns often involved efforts to influence underlying social issues that affect health behavior. HCP campaigns often challenged gender norms that influence both men s and women s ability and decisions regarding health practices. Some campaigns were designed to directly raise consciousness and promote dialogue about social issues such as alcohol abuse, violence against women, HIV stigma, smaller family size, and discussions within couples about HIV status, male circumcision, and family planning. 4: Improve community mobilization capacity HCP worked in partnership with community based organizations and resource persons to improve their ability to discuss health issues accurately and 8 The HCP Project Final Report July

9 to get their communities more involved in priority health issues. HCP developed materials, interactive games/exercises, and tools for use by partners at the community level. Trainers were trained in the use of materials and approaches and then cascaded training to other community resource persons. HCP also assisted the MOH to produce a radio distance learning program for VHTs that refreshes and updates them on priority health issues, practices and services. 5: Form strategic partnerships with leaders and media representatives HCP worked to develop and train media partners to improve reporting on health and underlying issues such as violence against women, stigma, couple HIV counseling and testing, safe male circumcision, family planning, and alcohol. Also, by working through cultural, political and religious leaders at community, district and national levels, support was generated to promote the health and social practices addressed by campaigns. 6: Strengthen strategic communication capacity In an effort to ensure that proven communication processes and principals by embraced by SBCC organizations and practitioners, HCP conducted collaborative capacity assessments with partner organizations early during the project. Theses assessments helped HCP to identify gaps and areas for strengthening, and offer appropriate training opportunities for partners, collaborators, and HCP Uganda staff. HCP provided mentorship and hands-on guidance for research, strategy design and materials development for many of its partners, organized opportunities for SBCC partners to coordinate and share, and shared lessons learned and promising practices through research dissemination meetings, peerreviewed articles, conferences and workshops. HCP also established and managed an internship program for recent graduates from Ugandan universities, and has made all resources and materials produced under the project available on an electronic library at the MOH and through a set of eight online electronic toolkits. Religious leaders are important allies in health communication when they have accurate information and understand the health benefit of certain action. Pictured is Rev. Sam Rutaikara a religious leader who was willing to talk about safe male circumcision during the Sanyu breakfast show, a popular radio programme in Uganda. 7: Build coalitions and strengthen partnerships HCP worked with coalitions of national and districtlevel stakeholders for input into priority health communication needs, strategy design and development of communication tools and materials. Throughout the project, HCP coordinated the national behaviour and social change communication group to share practices, tools, materials, approaches, opportunities, and research findings. HCP also worked in close collaboration with national working groups chaired by the MOH or informal technical advisory groups. These collaborative partnerships resulted in wide spread ownership and participation in communication interventions supported by HCP, increasing their reach and overall effects. The HCP Project Final Report July

10 Voices Collaborative Partnerships During the last five years, HCP has cultivated partnerships with over 75 organisations from the Government of Uganda and its implementing partners. Without these many types of partnerships, HCP s results would have been less impressive. One group of partners is the national working groups or technical advisory teams. Involving these key players throughout the communication process meant that what was produced was accurate, up-to-date and supported the national polices and strategies. There was also broad buy-in and endorsement. Another group of partners are the organizations working with particular groups of people such as people living with HIV or within a specific intervention area such as counselling and testing. By working with these partners, communication interventions expanded far beyond the reach of HCP alone. A third group of partners chose to invest in health communication. These partners have acknowledged the effectiveness of certain interventions by choosing to provide financial or in kind support. Partners such as CDFU, PSFU, World Vision, Save the Children Uganda, and STRIDES for Family Health have ensured the sustainability of the National Health Hotline, Rock Point 256 and the GOLD internship programme. HCP is grateful for these partnerships and appreciates the voices of these partners throughout this report that help tell the story of our partnership in health communication over the last five years. HCP has helped us to see that you cannot just wake up and say this or that needs to be done, but instead they took the time to get information from the consumers the clients and showed us to always ask why first. - Dr. Akol Zainab Former Program Manager AIDS Control Programme, MOH HCP has listened and let us be the lead. So we own the concepts and the materials. - Apollo Kansiime Program Officer Home Based Care, MOH They [HCP] share it all for us to do what we want they do not say the materials are HCP s, but that they are MOH s so that everyone can use them and identify with them. - Dorothy Balaba Country Manager Reproductive Health, PACE HCP has changed the mood of how IEC materials are done for the whole country. They have had such a flexible way to make the resources work... they have also listened to the partners on the ground, and you will not get many organizations to do that. - Dr. Raymond Byaruhanga Executive Director, AIDS Information Centre HCP plays a central role in developing materials and the design of messages for services. We are the outlet for their product. And their product is designed to support what we do. The materials can be standardised and used across cultural nuances. - Dr. Edward Bitarakwate, Chief of Party, Star SW

11 Research Monitoring and Evaluation Research, monitoring and evaluation (RM&E) are the backbone of effective health communication. Beginning with formative research, which helps define the health problems, audiences, and strategic approaches of communication strategies; pilot testing to guide the development of materials and activities; monitoring to ensure communication programs are implemented according to plan; and ending with evaluation of the reach and effectiveness of communication interventions, RM&E is an integral part of the entire communication process. HCP has worked closely with MOH and partners to ensure that institutions understand how and why communication campaigns are developed based on research. HCP also helped to strengthen the skills of key players in these institutions to be able to carry out effective communication research after HCP is gone. HCP is very strong in the area of research. They start the process from research, to concept development, to testing, to modifying and not until then are the materials distributed. This ensures that people identify and find the messages meaningful. It s much better than us just sitting here deciding what to put on a poster. - Dr. Paul Kagwa, MOH Research helps us use the way they talk it turns their words into messages. - Richard Baguma, Uganda Health Communication Alliance HCP s Research, Monitoring and Evaluation Conducted two household surveys in 2008 and 2010 to assess the reach and behavioural effects of HCP supported communication interventions. HCP also spearheaded the design of the USAID Joint BCC Survey, which will be conducted in 2012 to provide information about the effects of communication interventions conducted by HCP and other implementing partners. Conducted seven formative research studies to inform the design of communication strategies on unmet need for family planning, adherence to ART, safe male circumcision, complications associated with traditional male circumcision, alcohol abuse, HIV discordance, and HIV stigma and discrimination. Conducted 84 pretest exercises for radio spots, TV commercials, posters, bill boards, flip charts, logos, grain sack charts, training manuals, health education videos, discussion guides, and job aids Conducted evaluation studies for the VHT radio distance learning program, the Be a Man campaign, and the National Health Hotline. Submitted abstracts and delivered presentations on Paediatric HIV, the Rock Point 256 radio serial drama, SMC, HIV stigma, and family planning at five national and international conferences in Africa, Asia and the United States. The HCP Project Final Report July

12 Key HCP Project Learnings Communities and individuals are the creators of health; health communication needs to provide balanced information that allows people to make informed choices. A collaborative and participatory approach to health communication design and implementation strengthens partnerships and ownership of project outcomes, and leads to lasting changes in health communication and service delivery. Effective communication strategies draw on evidence-based practices, a thorough analysis of health issues, input from audience representatives, and utilisation of relevant behavioral theories. Strengthening capacity for health communication at all levels from individuals at household level to service providers, community leaders, the media, and national leaders improves the reach and effects of communication efforts. Health communication that addresses barriers to change at more than one level of society is more likely to result in adoption of health practices. Communication is a two-way process. Monitoring and evaluation are necessary in order to get feedback and adjust messages and approaches so the messages reach the right people, are understandable and relevant. National communication efforts need a minimum of two years to allow for proper design and at least a year of implementation. Project documentation should begin from the first day of the project. 12 The HCP Project Final Report July

13 Integrating Health Communication: A Sustainable Approach HCP funded radio programmes and radio listener clubs to start discussions such as the VHT distance learning programme, updating these community workers on concepts and how to address child and maternal health challenges. This has been very, very, very helpful. - Dr. Paul Kagwa, MOH

14 National Health Hotline When communication reaches the communities, some audiences require more than one message; for instance, sexually active adults require information about prevention of HIV as well as information about family planning. Providing channels for communicating about the full package of health practices and services for a particular audience, is a cost effective and efficient approach. In addition, by integrating the communication across health areas, a broader spectrum of implementing partners can be engaged in supporting the initiative, thus making it sustainable beyond HCP. This section highlights two interventions that have used an integrated approach to health communication: the National Health Hotline and the Radio Distance Learning (RDL) programme. Both interventions will continue beyond June 2012 with support from HCP partners. National Health Hotline Many Ugandans, especially those residing in rural areas, lack access to quality health services. Lack of updated health information, fear and discrimination, and financial constraints are key factors that prevent people from accessing health services and vital life-saving information. Between 2007 and 2008, HCP through the Y.E.A.H. initiative conducted a mapping exercise, which identified a dearth of youth-friendly services as well as a complete lack of specialized services to address alcohol and violence against women. While local radio programs supported by HCP and others, had begun to host health professionals on live phone-in radio talk shows, the number of callers and the issues raised far exceeded what could be tackled in a one-hour radio program. People simply did not know where to go for needed services or whom they could get information from to make an informed health decision. This identified health information gap, coupled with evidence that by 2010 more than 10 million Ugandans would have access to mobile phones, sparked the idea of a free telephone counseling and referral service. The service would provide timely, accurate and reliable information to people about health issues and available services. In 2009, UAC and MOH, through Communication for Development Foundation Uganda (CDFU), with technical support from HCP took steps to establish a National Health Hotline [ / ] to provide health information to callers from all parts of Uganda. The anonymous and confidential nature of the hotline enables callers to divulge vital health information and to remain in an environment of their choice. HCP provided financial and technical assistance to set up the hotline, on-going technical support to CDFU in the day-to-day management of the hotline, and assisted in developing quality assurance mechanisms. Results The Hotline is meant for counseling, information and guidance and we re definitely interested in seeing it continue. - Dr. Paul Kagwa, MOH The demand for hotline services is overwhelming. The Hotline receives up to 46,000 calls per month from callers across Uganda, including those residing in rural and peri-urban areas. With the available funding to date, the hotline has been able to hire and train 12 counselors and operate Monday to Friday, 8 am-5 pm. However, this is not enough to meet the high volume of calls. Between 2010 and 2012, the hotline has responded to over 150,000 calls but they have received more than 10 times that number of calls. Thus the need to expand the hotline services is apparent. Since October 2009, when the hotline first began, CDFU has received over 1,500 calls from clients appreciating the services offered. The majority of hotline callers are men. In researching the reasons for this, HCP found that this is the case with most telephone hotlines throughout the world. In an effort to identify why men use the hotline, HCP conducted a follow up survey of hotline callers in May, 2012, which will be shared on the Hotline etoolkit. 14 The HCP Project Final Report July

15 The Hotline has also helped address the issue of low health seeking behavior among men % of the callers to the hotline are men! - Anne Gamurorwa, CDFU Hotline Caller Feedback I want to thank the counselor for supporting me, I was confused after testing HIV positive and I went to Masaka referral hospital where the counselor had told me to seek HIV treatment. I was retested and given Septrin drugs, and they told me to go back for more when these are finished, caller from Masaka District. After your counseling, I took my wife for family planning and they inserted an IUD, caller from Apac District. I called some time back and with a problem of my girlfriend and you helped me, she accepted to go with me for HIV testing and we are okay now thanks a lot, a caller from Mitooma District. I called to thank you for helping my sister to have hope, she is HIV positive but had refused to take the medicine but with your help and support she is now okay and taking her medication properly after talking to one of your people, caller from Kanungu. Besides helping individuals with health information and counseling, the hotline also provides feedback from the public on health communication campaigns. For example, when UAC and Y.E.A.H. launched the True Manhood Alchohol Campaign in July, 2009, there was a sudden up-surge in callers requesting information and counseling about alcohol abuse. Alcohol-related calls continued to dominate until January, 2012, when the MOH launched the Safe Male Circumcision (SMC) demand creation campaign. Between January and April, 2012, the majority of calls were about SMC. CDFU conducts content analyses of calls on specific campaigns, which provides useful feedback on information needs and quality of health services. For example, in February, 2012, the hotline received calls from men who had gone for SMC and Graph showing the number of calls answered by the complained about the quality of services at specific hotline between facilities. The hotline shared this information with the implementing partners working in those areas of the country so that they could follow up. Many partners have realised the value of the hotline in reaching men and women with health information; STRIDES for Family Health, Uganda Health Marketing Group (UHMG) and Plan Uganda are currently sponsoring some hotline costs while others have expressed interest in partnering with the hotline in the near future, such as: PACE, Mulago- Mbarara Joint AIDS Program (MJAP), Save the Children in Uganda, Private Sector Foundation Uganda (PSFU) and United National Population Fund (UNFPA). The HCP Project Final Report July

16 Radio Distance Learning Uganda is implementing the Village Health Team (VHT) strategy to ensure that every village has VHT members who work together to mobilise the community for better health and refer individuals to health services. VHTs are community mobilisers and need to be equipped with relevant and up to date knowledge and skills on a regular basis to enable them do their job. However, with the large numbers of VHTs in the country, the costs of face-to-face training is prohibitive. In response, the MOH in collaboration with HCP and other partners developed a cost effective way of providing refresher training and continuing education to VHTs through a radio distance learning programme (RDL). The programme enables a large number of VHTs to learn at a relatively low cost and has the ability to reach those with low literacy and living in rural areas. Radio has the widest reach of any communication channel in Uganda. Seventy percent of rural women and 87 percent of rural men listen to the radio; and listenership is even higher in urban areas (Uganda Demographic Health Survey (UDHS), 2006). The pilot phase of the programme supported by HCP and implemented through the district health structure reached 12,000 VHTs from the districts of Lira, Otuke, Alebtong, Mukono, Mpigi, Wakiso, Masaka, Gombe and Rakai. It focused on roles of VHTs, family planning, HIV counselling and testing, HIV prevention and treatment in adults and children, alcohol abuse and violence against women. The second phase of the program, which is currently being produced by MOH and World Vision Uganda focuses on maternal and child health, malaria, hygiene and sanitation, and tuberculosis. Results An evaluation of the program in Mukono showed that VHT s knowledge improved on all health issues covered in the program. Knowledge of at least three benefits of family planning almost doubled from 22% at baseline to 40% at follow up, while the proportion of VHT members who did not know any benefit of family planning drastically dropped to 0. The level of knowledge of SMC benefits among VHTs enrolled in the program as the percentage of those who could mention all the three benefits correctly increased five-fold. The evaluation also found that VHTs meet in groups to listen and discuss the programme, which enhances dialogue and sharing of experiences. Overall, the majority of the VHTs interviewed in the evaluation felt that the weekly radio programmes (83%), the listener s guide (77%), and the listening groups (82%) were effective methods of providing refresher training. Because radio has a wide coverage, community members also listened to the programme; this enhanced recognition and appreciation of VHT work by the wider community. A community member interviewed reported, They (VHTs) have been sensitising us about the dangers of bearing so many children and encouraging us to consider using modern contraceptives. The program also strengthened the link between VHTs and health workers by advising VHTs to consult health workers when they had any questions, and providing the phone number of the District Health Educator (DHE) for answers to questions. Sustainability Due to the promising nature of the program and its ability to reach large numbers of VHTs at a relatively low cost, World Vision Uganda has committed to continue supporting the MOH to continue the radio distance learning program after the end of HCP. World Vision is providing technical assistance to the MOH to produce new radio programmes and discussion guides for 13 new sessions focusing on maternal and child health issues, expand the reach of the programme to more districts and share programme materials with other partners that wish to implement the programme in districts where they operate. We need strategies to promote group learning so you can address the barriers, come together to explore issues. RDL brings people together. It is creative learning beyond a workshop. We want to sustain an innovative strategy that HCP has started. - Richard Kintu, World Vision 16 The HCP Project Final Report July

17 Voices Bringing VHTs Together for Learning and Sharing In Kimanya village, just outside Masaka, five VHT workers are gathered for a Radio Distance Learning session; a hugely successful HCP initiative focused on updating community volunteers on essential health issues and practices. We listen to the radio programme and follow the specific topic in the books we have been given by the DHE, says Charles Ssenyongo, one of the VHTs, explaining how the sessions work. Afterwards, we discuss the programme as a group, using the questions in the book to discuss the topics and to reach conclusions together on how we can implement the practices in our villages. We have learnt so much from this and, as a result, get such a good response in the communities. For me, some of the most important things I have learnt from the sessions have been clarifying my role as a VHT, how to advise on appropriate family planning methods, how to counsel HIV positive mothers and children, and how to address sensitive issues such as alcohol abuse and violence against women. All the VHTs gathered agree that the learning programme has had a direct, positive impact on their communities. I helped one family just near here with family planning advice, says Akena Raphael. They were really struggling to provide for their eight children, and after our discussion they have now started using contraception to avoid having more children. Even myself, I decided to stop with our third child after learning about family planning. A lot more people are also getting tested for HIV, continues Ssempa Joyce. Before, they would often fear the results, but because we explain how and where to get treatment if you are positive, more people are willing to find out their status. Stigma is also a big issue here. I helped one family that was discriminated against and tortured by their community because their children were HIV positive. Now, after counselling the family, their friends and neighbours, they are once again included in their community. Before the radio sessions, the only way we would receive training was through seminars organized by the district. But they didn t happen very often I guess it is more expensive that way and takes more organising. So back then, all we really knew was how to distribute drugs. Because of the radio programmes we now know how to care for pregnant mothers and new-borns, how to prevent malaria and improve health through better hygiene and sanitation. Now, we are much better VHTs. HCP have made a big difference in improving health communication activities. In particular, they have developed and funded radio programmes and radio listener clubs to start discussions such as the VHT distance learning programme, updating community workers on concepts and how to address child and maternal health challenges. This has been very, very, very helpful. - Dr. Paul Kagwa, MOH The HCP Project Final Report July

18 Promoting Family Planning I am 22 years old and have a three-year-old boy. I listened to Nurse Mildred talk on the radio about the benefits of spacing your children. She gives guidance and help in family planning. Because of that I came here to the Marie Stopes clinic, because I don t want to conceive yet, I want to give my boy more time. My husband came too; you have to be united so you can both learn more. There is no need for secrecy. Before I only knew about two methods of family planning; now I know them all. - Susan Alyebo Nurse Mildred Listener in Soroti

19 Family Planning Communication Uganda has the third fastest growing population in the world at 3.2%, and total fertility rate of 6.7 children per woman. The rapid growth of the population has serious implications for Uganda s social and economic development and national aspiration to evolve into a middle-income economy over the next 25 years. According to the UDHS 2006, only 24% of married women in Uganda currently use modern family planning methods; 41% of women would like to delay or stop having children but are not using modern family planning, and therefore, have an unmet need. The main reasons for non-use, according to that survey, were fear of health problems or side effects, and husband s disapproval. Efforts aimed at decreasing unmet need and increasing contraceptive prevalence in Uganda can substantially reduce the country s total fertility rate and population growth rate. From , HCP has supported MOH to implement two national, multichannel communication campaigns aimed at increasing male involvement in family planning and reducing the unmet family planning need. HCP provided support to the National Family Planning Working Group and Maternal & Child Health cluster group throughout the entire project period. Each year, throughout the two campaigns, MOH reached over 8,500,000 individuals with media messages on family planning practices, and provided IEC materials on family planning practices and services to more than 500 institutions and 1,500 leaders, service providers and community health workers and volunteers. All materials and messages directed couples to family planning services labelled with the rainbow over the yellow flower, and to the National Health Hotline for information, counseling, and referrals. HCP also oriented over 700 university students, faith based leaders and media representatives on family planning policies and strategies; and directly provided family planning orientations and trainings for over 100 DHEs, 600 VHTs and 700 health workers. Being able to have families that are manageable, can take care of properly and educate, is the message Rev. Eridard Nsubuga has been preaching to his flock at the Luwero Diocese Church located about 100 kilometers north of Kampala. Religious Leaders Endorse Family Planning He preaches this message through church groups like the Mothers & Fathers Union that meet every Tuesday at the church Religious leaders during a training on family planning. gardens. During premarital counseling, Rev. Eridard also reminds couples about the importance of family planning, child spacing, and birth control in the context of the high cost of living in Uganda. He refers people to one of the six health centres run by the Luwero diocese. With the belief that religious leaders play a vital role in influencing behavioral change in society, HCP has worked with partners such as the Inter Religious Council of Uganda (IRCU) to actively engage religious and cultural leaders in the national family planning revitalization campaign. To date, over 500 religious leaders have participated in a series of trainings on family planning methods, taboos, myths and misconceptions and the majority of them have started preaching about family planning. During such trainings, religious leaders are given information education and communication (IEC) materials for them to use for reference while preaching. The HCP Project Final Report July

20 Male Involvement Campaign Fred and Bernard Campaign - Male Involvement The first campaign, from , focused on increasing male involvement in family planning. The specific objective of the campaign was to increase the proportion of men who want to have smaller families and who discuss family planning with their partners. The campaign revolved around two characters: Fred, who had a large family and was struggling to provide for them; and Bernard, who had a small family and was able to provide for their needs. This Fred & Bernard Campaign was centred on a radio mini-drama series, Neighbours, which reached millions of Ugandans across the country. The campaign also used radio spots, television adverts, posters, and billboards to communicate the key message to men: smaller families for a better life. HCP also worked directly with MOH and partners to implement menonly community outreach activities, and to develop job aids and client education materials for health workers, VHTs, and clients. Throughout the campaign, over 550,000 IEC materials were distributed to more than 2,500 health facilities, 4,000 leaders and 1,000 institutions. We (MOH) have networks in the districts and HCP has really supported us to get them together and we want more of it because this is really national capacity building. HCP has initiated these meetings and helped to make sure people buy in and this is so important because these district level people are our communicators for the whole country. - Liliane Luwaga, MOH Smaller Families, Better Lives Neighbours, a radio mini-series, was an innovative strategy developed by HCP to communicate Uganda s population crisis to men. Neighbours revolved around the lives of two key characters: Bernard (who has planned his family and has few children) and Fred (who has not planned his large family). Neighbours won the 2009 Global Media Award for Best Radio Drama from the Population Institute. 20 The HCP Project Final Report July

21 HCP involves us (MOH) as true partners right from the inception of their projects, not just in developing the materials, but in conceptualizing the ideas. - Lillian Luwaga, MOH Men Only Outreaches As part of the Fred and Bernard Campaign, MOH and HCP developed a strategy to get men behind family planning called Men Only Outreaches. The outreaches are half-day events designed to inform men about family planning and help them to open up and discuss family planning in an environment where they feel free to express themselves. During these events, the central messages to the men are: having a small manageable family is key to a better life and men are important in planning a family. The outreaches are for adult men of all ages and follow an entertainment- education model. The day includes formation of teams of men who participate in entertaining activities, such as: competitive sports, mini football league, dramatization, board games, and educational sessions. The educational sessions include viewing family planning videos, listening to presentations on population and development and family planning methods, and testimonials from men using family planning methods, followed by a quiz. Each of the men receives a booklet on population and development and the family planning methods to take home and discuss with his wife. At the end of each event, prizes that encourage couples discussion about family planning are awarded to the mini-league winning team members. Results The HCP 2010 Survey evaluated the reach and effects of communication efforts conducted by HCP between Key findings from this survey revealed exposure to the Fred & Bernard Campaign was independently associated with many family planning related behaviors. Respondents who had been exposed were more likely to have positive attitudes towards family planning, advocate for use of family planning services, prefer a smaller family, discuss family planning with their partners, intend to use family planning, and use family planning methods. Actions Taken as a result of exposure to messages about Fred & Bernard Decided to have a small family Spoke with my partner/spouse about family planning Discussed the number of children to have with my spouse/partner Visited a clinic for family planning services Discussed population growth and development with my friends/relative Participated in community activities Visited a health facility to get more information about family planning Was influenced by Fred & Bernard Messages % of Respondents The HCP Project Final Report July

22 Unmet Need Campaign The second campaign, Nurse Mildred, ran from 2011 to 2012 and targeted rural and peri-urban women with unmet need for family planning and their partners, with the aim of convincing them of the safety and effectiveness of modern family planning methods. According to qualitative research conducted by HCP in 2010, most women using modern family planning methods had spoken with a health worker, unlike women with unmet need who usually got information about family planning from friends and family. The Nurse Mildred Campaign centered around a weekly radio drama and call-in talk show series broadcast in English and six local languages and run simultaneously in 16 radio stations across the country. The Nurse Mildred Show featured the kindly and knowledgeable Nurse Mildred, who corrects myths and misconceptions about modern family planning methods, encourages couples to discuss spacing and family size and explains the link between family size and poverty. The campaign also addressed the need to improve attitudes and communication skills of service providers to offer quality family planning services. All materials focus on countering the most common negative misconceptions about modern family planning, and direct couples to health facilities labeled with the rainbow of the yellow flower or the National Health Hotline for information, counselling and services. The Nurse Mildred Campaign will be formally evaluated through the 2012 USAID Joint BCC Survey, which will be fielded in May However individual case studies gathered by HCP in early 2012 revealed that the Nurse Mildred Show is effective in reaching men and women with relevant information and in influencing them to take action, as expressed by Nurse Mildred Show listeners. 22 The HCP Project Final Report July

23 Voices A Real Life Nurse Mildred There is an unmet need of family planning in communities; deep in the villages people don t have the awareness. The Nurse Mildred campaign creates demand and awareness, and dispels myths and barriers. On air, we talk about the different methods of family planning and listeners can ask questions the most common questions are on side effects. The show lasts for one hour, and we get an average of ten callers per programme. Nurse Mildred is famous. She is known as a person who serves the communities with respect, she is a good person, and she dispels myths and misconceptions. Working for Marie Stopes, I am already serving the community, but I wanted to do more so that is why I agreed to be Nurse Mildred. I want to reach the ones who don t already have awareness of or access to family planning methods. It is important because it helps both the parents and the children. When spacing your children, the mother has time to recover to her normal state; the father has time to plan for better schooling and feeding; and the child gets more love and necessities. The training we had before the Nurse Mildred show included basics on family planning, radio skills, and how to talk to communities. The first time it was hard, but now I have practice. One of the things we encourage on the show is male involvement. Women used to come for family planning on their own, but we encourage them to bring along their husbands, as they need to receive the information and know about side effects as well. We definitely see more couples here at the Marie Stopes clinic as a result. And on the show we actually get more calls from men than from women, which would never have happened before. Lillian Aloket is a Nurse Mildred on Radio Etop in Soroti. with his family. We have two children already and we are happy with the method we chose. We have had no problems and my wife has not suffered any side effects. A 36 year old man from Gulu explains, I heard about family planning from a certain nurse on radio called Mildred. I then talked with my wife Rukia about the show and we listened together. We then decided to go to hospital to get the services and we chose the coil among other methods of family planning recollects Juma in the photo on the right Juma, pictured above with his family in Gulu, is a 36 year old boda boda driver, who is a satisfied family planning user. The HCP Project Final Report July

24 Empowering Young People to Make Healthier Choices (Y.E.A.H.) In Y.E.A.H. they have been very powerful, with their radio campaign linked to youth groups, comic books and other mutli media. There has been a generational shift in the way young people see HIV, women and empowerment. - Richard Kintu, World Vision 24 The HCP Project Final Report July The Rethinking Drinking flipchart helps police Community Liaison Officers, teachers and peer educators communicate with small groups about the problems that occur when people abuse alcohol.

25 In a country where young people make up half of the population, the Government of Uganda realizes that young people must be a key part of any strategy to combat major health threats, such as HIV. Therefore, starting in 2003, the National Strategic Framework for HIV and AIDS in Uganda called for improved coordination and intensity of communication efforts for and by young people. In response, UAC, working with most organizations serving young people in Uganda, developed a conceptual framework to address six key issues that influence young people s ability to adopt healthy sexual and reproductive health practices. The framework articulates layers of political, social, cultural and personal factors that affect a young person s ability to adopt healthy practices. Over the last eight years, Y.E.A.H. has been managed by CDFU on behalf of UAC and works through a network of approximately 500 partner organizations throughout Uganda to implement activities at district and community levels as well as provide input into the design of campaigns, materials, and interventions. Y.E.A.H. relies on funding partners, implementing partners and Regional Lead Organizations (RLOs). RLOs receive funds from Y.E.A.H. to support communitybased activities of young people advisory groups and peer educators from community-based organizations. YEAH: An Initiative By and For Young People Based on this conceptual model, HCP established the Y.E.AH. initiative in 2004 as a coordinated and branded initiative for young people years aimed at reducing their risks of HIV, other STIs, unplanned pregnancies, and early school leaving. The initiative is led by the UAC in partnership with various organizations working with young people in Uganda and with technical support from both HCP awards ( & ) and funding from the USAID. Y.E.A.H. is fully implemented by and for young people. Young people are involved in each stage of the development of strategies including analysis and design, materials development, implementation, monitoring and evaluation. HCP has trained young Ugandans to write and produce Rock Point 256, who are now responsible for about 85% of the production process. By involving young people so extensively, Y.E.A.H. builds young people s leadership skills and confidence, and remains relevant to the real situations facing them. Y.E.A.H. Campaigns Over the last eight years, Y.E.A.H. has developed and implemented five major multimedia, multi-channel campaigns to stimulate discussion, self reflection, and community action concerning key underlying factors that create risk in young people s lives. The HCP Project Final Report July

26 Y.E.A.H. Between 2007 and 2009, Y.E.A.H. continued implementing the multi-channel Be a Man campaign, which promoted gender equitable attitudes, faithfulness and non-violence in sexual relationships, HIV counseling and testing, condom use, and abstinence. HCP also assisted Y.E.A.H. to develop the Men and HIV training manual, which was used to train trainers from partner organizations and community outreach workers. The True Manhood Campaign: In June, 2009, Y.E.A.H. launched the True Manhood campaign, which targeted young women as well as men because feedback from young men revealed that they could not change the way they interacted with women unless the women also changed their attitudes. The True Manhood campaign was rolled out in three phases. 1. From 2009 to 2010, HIV prevention was repositioned as a masculine trait: True manhood means doing what it takes to prevent HIV. Multimedia and interpersonal activities were designed to encourage young men to abstain from sex, stick to one partner or use condoms; know their HIV status and that of their partner; drink alcohol responsibly or not at all; and treat sexual partners non-violently. 2. From , the True Manhood Alcohol Campaign encouraged young men and women to drink responsibly or not at all. Alcohol abuse is a serious problem in Uganda, where per capita alcohol consumption is the highest in the world, according to a World Health Organisation (WHO). A study conducted in Rakai, Uganda, between 1994 and 2002 found that alcohol consumption before sex increased the risk of acquiring HIV infection by 67% for men and 40% for women (Zablotska et al. 2006). To address this, Y.E.A.H. developed interactive tools and trained peer educators, teachers, and police officers in their use, and reinforced these activities with radio and television programming, billboards, fact sheets, and alcohol self-assessment check lists. 3. From 2011 to 2012, the True Manhood Violence Against Women Campaign aimed to convince young men to treat their partners non-violently and to encourage other men to do the same, while educating men and women about the new Domestic Violence Act, which spells out what victims of domestic violence should do to protect themselves. Violence in relationships is often 26 The HCP Project Final Report July

27 associated with alcohol abuse and infidelity, both of which increase one s risk of HIV; and women who are in violent relationships are usually afraid to insist on condom use and HIV testing, or to disclose their HIV status to their partner if they are positive. In most cases, violence against women is the result of power imbalances in relationships. As with the other True Manhood campaigns, Y.E.A.H. used a combination of interpersonal and small group activities and media to stimulate discussion and introspection among young men and women about violence. The characters for both the radio programme and the comic books demonstrate everyday people s journeys from ignorance of a desired health practice, to awareness, to understanding, to deciding to adopt a new practice, and eventually to adopting and making the practice a way of life. The stories draw on audience research in Uganda so that the real challenges and setbacks that young people face inspire the creative tension and conflict that make the stories of change believable. The theory behind the use of entertainment for behavior change is that audiences will identify with the characters and their situations, and imitate their actions and attitudes in real life, thus leading to behavior change. Rock Point 256 radio serial drama and comic books are popular because they are entertaining, and they were educational because they are designed to model young people s journeys to healthier behaviours. Rock Point 256 The centerpiece of the Y.E.A.H. initiative is the weekly radio drama and comic book series entitled Rock Point 256. Over the last seven years, 293 half-hour episodes in four languages on 16 radio stations have been produced and broadcasted. Each year, the radio serial drama carries four storylines each focused on a specific health or social issue. The issues covered by Rock Point 256 since 2007 include: multiple concurrent partnerships, couple HIV counseling and testing, alcohol abuse, violence against women, prevention of mother-to-child transmission, family planning, safe male circumcision, something for something love, and faithfulness. Since 2007, four comic books in five languages were produced by Y.E.A.H. Each comic book captures one storyline in a format that community resource persons can use to facilitate discussions on the issues. The HCP Project Final Report July

28 Other Y.E.A.H. Innovations To complement the campaigns, Y.E.A.H. works with partners and Young People Advisory Groups (YAGs) to develop small group, community-based and interpersonal communication interventions. These activities require little to no technology and help young people to personalize and internalize campaign messages, such as the string game, which is a simple, low cost method of demonstrating what a sexual network is and why it is risky. Y.E.A.H. trained 1,984 resource persons throughout Uganda to facilitate discussions using the tools and approaches and to train others in their use. As explained by Mugamba Denis (pictured above), a YAG from Reproductive Health Uganda in Mbarara: YEAH uses many communications tool, using infotainment to get health messages across to the youth. The trigger video provokes the audience to discuss, to think about what happens next. And because it is silent, it works across different cultures. And because it is just a DVD it is easy to use and it s portable. The discussion guide is very useful, you really need it in order to guide the conversation towards topics you want to discuss otherwise you can easily get distracted. Other tools such as comic books, manuals, posters and games are really helpful in engaging young people. Through these, young people find it easier to identify what exactly it is they do, how their behaviour can have consequences. Sometimes, when they see messages on billboards or get information from the radio, they re not always sure of what they mean. But then they come here and through the activities we emphasize these messages and they can then connect the information and relate it to themselves. The trigger videos were awarded First Runner Up in the 2009 AfriComNet Annual Awards in HIV communication. 28 The HCP Project Final Report July

29 Results 1. According to the 2010 HCP Survey, 71% (82% urban; 66% rural) of young people surveyed in 31 districts said they had been exposed to at least one Y.E.A.H. activity or material in the past year. 2. Young people exposed to Y.E.A.H. communication were more knowledgeable about HIV, had more gender equitable attitudes, and were significantly more likely to abstain from sex, use condoms at last sex, intend to test for HIV, and stick to one sexual partner than young people who were not exposed. Comparison of Year Old Rock Point Listeners and Non-listeners 3. The most wide reaching Y.E.A.H. medium was Rock Point 256, which has been listened to by 56% of young people and 50% of adults, and reached 31% of the young people at least once a week, according to the 2008 and 2010 HCP surveys. 4. Y.E.A.H has so far established partnerships with more than 500 Ugandan and international organizations, reached more than 215,000 young people through interactive small group sessions and an estimated 2.9 million young people each year through its award winning national weekly radio serial drama, Rock Point Since July, 2007, through over 21,866 letters, text messages, messages, and telephone calls, young people describe their personal struggles with Something for Something Love, alcohol, faithfulness, or violence and have asked for advice about HIV or pregnancy. Many have formed Y.E.A.H. or Rock Point listener clubs and discussion groups. 6. By the end of HCP, Y.E.A.H. had leveraged sponsorships to continue production of Rock Point 256, and 22 radio stations have agreed to broadcast the program free of charge for an additional six months. This is only possible because the radio series is engaging, entertaining, and most importantly, popular The HCP Project Final Report July

30 Voices Rock Point was the turning point for me This went on for five years. The turning point, for me, was when I started listening to Rock Point 256. It is what helped me stop. The stories on Rock Point were the same as in my environment and my experience, and it made me think about what we were going through and see the problems alcohol caused more clearly. I realised that if I continued, there would be even more problems coming my way, so I had better stop before it would be too late. And so I did. And I am much, much better now. Moses Ngabirano, an avid Rock Point listener Moses Ngabirano is 22 years old and just a few months away from graduating as a teacher. I have always wanted to become a teacher, says Moses. I love the profession you get to be a role model to young people, which is very important. I think I will be a good role model; I have a good reputation now, as someone who is responsible. Just a few years back, however, Moses reputation was far from responsible. Like a shockingly high proportion of Uganda s youth, Moses had fallen victim to alcohol abuse at the tender age of 14. I think I started drinking because of peer influence, explains Moses. Many of my friends were older than me and they would buy alcohol and give it to me, so I got hooked. It made me feel great, very excited, and as if I could manage anything. Like I could talk to girls, which I was too shy to do when I was sober. When I was drunk, I was even tempted to having sex. One time I came very close and had arranged everything with this girl my friend knew. But, luckily, something stopped me. I feared getting AIDS from this girl because I knew she went with many men. Now, I look back at that as a narrow escape. It affected my education as well. I used to be a very good student, but because of the alcohol I turned in to a failure. I didn t study and would skip class to stay in bed and, as a result, the people from my class back then are now at a better level than me. Through Rock Point I realised that if you take the advice, you can change your life. Even the first time I listened to the show, I knew it was better than the rest. It was more real. Whatever happened in the show, happened in the world around me. Like, for example, the Something for Something Love story; it made me think of my friend Sarah from P5. Just like in Rock Point, her guardian, the person who was meant to look after her, was abusing her sexually. Whenever she asked for school uniforms or books he would make her pay. She was only 14 years old. It made me feel so bad, I really pitied her, but I didn t know what to do to help her. She became more and more desperate and ended up as a prostitute. That is the last I ever heard of Sarah. But the Rock Point story made me think about her again. It made me think what I could have done to help her. But there was no Rock Point back then, so I didn t know what to do. None of us did. When I start teaching I will definitely use the knowledge I have gained from Rock Point. If I come across students with problems, I will try and relate it to Rock Point and help them get out of their bad situation. I know it is just a show, but I believe it works in the real world. It worked for me! Rock Point 256 has won three awards: the 2007 AfriComNet Award for Excellence in HIV Communication, the 2011 Best HIV/AIDS Program at the Africa Edutainment Awards, and in 2010 was voted the best radio program by New Vision readers. 30 The HCP Project Final Report July

31 Preventing HIV within Couples One of the best things HCP initiated is the Couple Counseling and testing. HCP has helped to influence the policy it is there now and so we have been able to move on to building skills and working with other partners on this initiative. The couple certificates were innovative and they sure made a difference. - Dr. Akol Zainab, MOH Sekakozi Joseph and Hadijah Nagita display their certificate after testing for HIV during an outreach at Kisekka Market in Kampala.

32 Promoting HIV Counseling and Testing for Couples Findings from the Sero Behavioral Survey confirmed that married couples in Uganda are at higher risk of acquiring HIV than those never married, accounting for an estimated 65% of new infections. The study established that multiple concurrent partners are common, condom use is low among couples, and that 43% of new HIV infections occur among HIV discordant monogamous couples. Discordance and non-disclosure of HIV status to partners were cited as major risk factors for HIV transmission. These results underlined the need to encourage couples to go for HIV counseling and testing (HCT) together. However, Uganda still lacked guidelines or national policy on couples HCT. In addition, health workers had limited capacity and tools to provide adequate counseling to couples. And, consequently, very few men or women knew their own HIV status or their partner s. Intervention In 2008, USAID and the MOH requested HCP assistance to change the profile of HCT clients from young, unmarried adults who repeatedly tested HIV-negative, to married and co-habiting couples. Working with the MOH and the National HCT Subcommittee (CT17) to design a couple HCT communication strategy, it became apparent that there was a need for a National Policy on HCT, guidelines on the provision of CHCT, and a National Training Curriculum. There was no way that the MOH could promote CHCT without having the services available. So, HCP and other members of the CT17 developed a national policy, guidelines, and training materials, which were shared among partners. With the policy in place, HCP worked in close collaboration with MOH and the AIDS Information Center (AIC) to design and implement a national, multi-channel communication campaign to encourage couples to use CHCT services. The campaign, known as Go together Know together, promoted couples HIV counseling and testing by getting couples who did not know their HIV status to recognize their risk of HIV, and by building their belief that CHCT will benefit their relationships. The campaign also identified CHCT services with an attractive logo, and educated couples where to go for services. For couples who had tested together, the campaign included specific messages for the three possible outcomes: both man and woman are HIV-negative; both man and woman are HIV-positive; or the couple is discordant. HCP worked closely with AIC to implement intensive community mobilization 32 The HCP Project Final Report July

33 activities using interactive radio programmes, community drama and video-taped testimonies, and worked with HCT service delivery partners to brand and publicize CHCT services to improve visibility and access. These activities were reinforced with radio and television spots, billboards, posters, and print and electronic media coverage. To recognize and reward couples who went for CHCT, the MOH and AIC distributed certificates to couples who had tested and gotten their test results together. Results The Go together Know together campaign continued from 2009 until 2012, expanding the number of partners implementing the community mobilization activities over time. In 2011, the campaign was nominated and emerged first runner up in the AfriComNet Annual Award for Excellence in HIV/AIDS Communication in Africa, in the multi-channel category. Furthermore, data from service delivery partners and evaluation studies reveal that the CHCT campaign influenced many couples to take action: AIC reported significant increases in the number of couples counseled and tested since the implementation of the campaign, from 31,093 in 2008 to 100,034 in ,386 calls on CHCT and 4,025 calls related to HCT were received at the National Health Hotline between 2010 and The HCP 2010 Survey found that more than half (53%) of the respondents exposed to the campaign were influenced to take action (see graph above). The couples counseling certificates are a great innovation that HCP brought on board. It takes a long time to get a man to test, so women cherish the certificate and that will stay for a long time. We take it for granted, but something like a certificate may make a meaningful difference in peoples lives. We always think money first, but a simple certificate has made many people come in for services. At least 30-40% who come to AIC are referred by couples who have tested and got that certificate. That is one HCP legacy it was innovative and has made us think how else can we get people to appreciate the service, to create demand for services. - Dr. Raymond Byaruhanga, AIC The HCP Project Final Report July

34 Promoting Safe Male Circumcision In 2007, results from three large randomized clinical trials in Kenya, Uganda and South Africa were published, showing that medically performed circumcision is safe and can reduce men s risk of HIV infection by 60%. Based on this evidence, the World Health Organisation (WHO) and UNAIDS recommend voluntary medical male circumcision as an essential part of HIV prevention programming. They further recommend that countries such as Uganda where HIV prevalence remains high and male circumcision is uncommon should promote the widespread adoption of voluntary medical male circumcision services as a means to reduce new HIV infections. Since then, HCP has been actively involved in assisting the MOH and partners develop and disseminate the National Safe Male Circumcision (SMC) policy and guidelines, educate the public about the research linking HIV prevention and medical male circumcision, create demand for SMC through a multimedia campaign, develop client education materials and develop communication for Ugandans living in traditionally circumcising areas that focuses on how to reduce risk of HIV transmission during traditional circumcision ceremonies. national SMC task force meetings, and when the new SMC policy guidelines and communication strategy were finalized, HCP provided assistance in disseminating them across the country, reaching over 1,000 leaders, health workers, civil society organizations and influential members of the public in 66 districts countrywide. The public education campaign ran from 2007 to 2010 and utilized public debates, live radio and TV talk shows, and newspaper columns with frequently asked questions on SMC to provide the public with easy to understand information about male circumcision and its link to HIV prevention. Media training sessions were conducted and electronic and print journalists were provided with accurate information on the role of male circumcision in HIV prevention and its wider benefits. HCP assisted the MOH to produce a flipchart, a question and answer book for health workers, and brochures for men about the procedure and its benefits. Public Education about SMC and HIV Prevention In 2007 when the research results were first reported, there was a media frenzy in Uganda, including incorrect information and exaggerated claims. Uganda had no policy to provide SMC services or to guide programming. Health workers were getting questions from clients and men were asking for circumcision services, yet the health workers lacked information or reference materials to help them educate clients accurately. USAID provided funding to HCP to assist the MOH to educate the public about the research linking HIV prevention and medical male circumcision, while the policy and guidelines were put in place. In 2007, MOH and Makerere University School of Public Health established a National Male Circumcision Task Force to conduct a national assessment of male circumcision services capacity and to draft a national policy and plans for the provision of safe male circumcision in Uganda. The task force also recognized an urgent need to provide correct information to health care providers, the media, and the general public, and requested HCP to assist them with this. HCP supported Results According to results from the HCP 2010 Survey, 39% of respondents had heard of the government policy on SMC. The results also confirmed that radio was the most common source of SMC messages, reported by 82% of respondents who had heard a SMC message in the 12 months before the survey. More importantly, among those exposed to messages about SMC and HIV, more than one-third reported that they took action due to these messages. Actions included talking to other people about getting circumcised (52%), talking to their partners about getting circumcised (17%) and, actually getting circumcised (5%). 34 The HCP Project Final Report July

35 Creating Demand for SMC By 2010, despite the supportive environment at the national level, only 25% of Ugandan men were circumcised (MOH 2010). Since projections calculated by PEPFAR and UNAIDS showed that if Uganda circumcised 4.2 million men within a period of 5 years, the HIV incidence will be halved, the MOH with support from the US government and its partners began to scale up the availability of SMC services throughout the country. Since demand creation communication was key to success in scale up efforts in Kenya, South Africa, and Tanzania, MOH requested HCP to assist with this effort in Uganda. At that time, there was no scale up plan, services were not mapped, accredited or branded, and community mobilizers lacked information, tools and skills to discuss SMC with men and women in their communities. In December, 2011, MOH launched the Stand Proud, Get Circumcised demand creation campaign, with the assistance of HCP and many other partners supporting the provision of SMC services. The campaign strategy is designed to convince men who already intend to circumcise to get safe male circumcision services, while encouraging women to support their men to get circumcised and to adhere to post-circumcision practices that promote healing. According to the 2010 HCP Survey, 41% of uncircumcised men said they intend to circumcise. The reason given by most men was that they want to reduce their risk of HIV. According to qualitative research conducted in 2009, the main reason men gave for not getting circumcised was that they did not know where to get the procedure or they were worried that the procedure would be painful. The majority of women who were interviewed wanted their men to be circumcised, and their main reasons were that they thought circumcised men were cleaner, and they wanted to reduce the chances that their men would bring HIV into their relationships. The Stand Proud, Get Circumcised Campaign builds on these findings. It uses a unique and provocative creative approach to convince men to act. It speaks to men through women. Using a multimedia approach with radio, video halls, television, billboards, brochures and posters, the campaign promotes SMC as a way that men can reduce their risk of getting HIV. It also reassures men that the procedure is not painful, and directs men to locations where services are available. MOH and partners have posted the SMC logo outside health facilities that offer SMC services, and campaign materials direct men and women to those services and to the National Health Hotline for more information and locations of services. The campaign also includes educational materials for use by service providers when educating and counseling clients and their partners both before and after SMC. Results The number of sites offering SMC services has increased from only 21 in 2007 to 120 sites in The number of SMC calls to the National Health Hotline rose from 220 immediately before the launch of the campaign (October to December 2011) to 1,557 calls (January March 2012). Although HCP is ending, the MOH and its partners will continue implementing the SMC campaign, which will be evaluated through the 2012 USAID Joint BCC Survey. The HCP Project Final Report July

36 Voices Creating Demand for SMC Long lines of mostly young men and boys are forming at the Itojo Hospital. All are here for free SMC services, offered as part of a nationwide HIV prevention campaign. We started offering the services on every Saturday in February, explains Michael Bavuga, the Nursing Officer in charge of the SMC team. This week we re running a special SMC camp, and through posters, radio announcements and community mobilisation we re seeing some good numbers 37 men the first day, 23 on the second, and so far today we have performed 50 procedures. While the clients are waiting, local VHT members carry out health education using flip charts and brochures provided by MOH and HCP. The materials are very useful, as all the information is there, says Nurse Michael. It is my impression that the messages are getting through; when asked why the men choose circumcision their first answer is mostly to prevent HIV and the second reason is hygiene. Trying to get a clear message across is very, very important, explains Dr. Moses, Programme Officer at STAR SW. If we were to just offer the procedures without proper education, it would be like throwing them in to the shark s mouth. It is very important that the clients understand that circumcision is to be seen as part of the ABC as opposed to pure protection against HIV. Though just 14 years old and not yet sexually active, Arinda Brian is here today because he heard of the benefits at church as well as on the radio. At church we were told that SMC can prevent the spread of STIs, says Brian. So when I heard the announcement on the radio about the free services at the hospital, I told my mother I wanted to go. Ashabe Damson, who is 15, also heard about the SMC camp on the radio. There was an announcement on the radio yesterday, that was the first time I ever heard of SMC, says Damson. But because I am scared of getting HIV I wanted the operation. It was all very quick and I didn t feel any pain at all. SMC district based partners have reported an increase in SMC uptake We only managed to circumcise 1,800 men for the period October December From January to March 2012 we are close to circumcising 15,000 men, explains Dr. Walakira Moses, Technical Director Strengthening TB and HIV & AIDS Response in South Western Uganda (STAR-SW). According to Dr. Kisembo Godfrey, Programme Officer SMC for Northern Uganda Malaria, AIDS and Tuberculosis Program (NUMAT), an implementing partner providing support to the SMC services in the northern part of Uganda, Before the HCP supported SMC campaign, we used to have problems with mobilization for services, but now we have no problems at all.

37 Preventing HIV in Traditionally Circumcising Areas Some groups in Uganda practice male circumcision as a religious or cultural practice. In eastern Uganda, the Bugisu conduct traditional male circumcision as an initiation rite every two years. Research conducted in traditional circumcising communities shows that the circumcision ceremonies involve many practices that increase the circumcision candidate s risk of acquiring HIV. As explained by Dr. Waniaye John Baptist, District Health Officer (DHO) in Mbale: In this area, almost all men undergo circumcision as a rite of passage followed by a big ceremony. We realised that certain aspects of the traditional way of circumcising negated the positive aspects of it. For example, there would be a lot of drinking during the ceremonies, which could lead to unprotected sex. There are other cultural aspects such as the newly circumcised man must have sex with an older woman that put a man at higher risk of getting HIV. And the traditional circumcisers would often use the same knife without sterilising it in between procedures. Therefore, although most men are circumcised, some of these communities experience HIV prevalence rates that are higher than the national average. In response to this, MOH with assistance from HCP and the Strengthening TB and HIV & AIDS Response in Eastern Uganda (STAR-E) Project, worked with a group of concerned citizens in the Bugisu region to develop an HIV prevention campaign entitled We are the Pride of our Tribe, promoting safer sex practices during the circumcision season, and an advocacy strategy aimed at convincing traditional leaders in that area to promote safe male circumcision for traditional initiation purposes. The campaign seeks to contribute to the prevention of HIV and STIs in traditionally circumcising areas by promoting abstinence, condom use, and partner reduction among circumcision candidates and their sexual partners, educating uncircumcised boys and their parents about availability of SMC services at particular health centers, and promoting dialogue among local leaders and community members about HIV prevention during the traditional circumcision season. Results STAR-E was careful in addressing such a sensitive issue, and they were intentional in their efforts to involve traditional leaders in the design of the campaign. A step-by-step initiation of dialogue around the practice of traditional circumcision, through joint meetings with cultural leaders and community meetings, built trust and helped establish relationships with traditional circumcisers on which other interventions can be built. Dr. Waniaye John Baptist, who has worked with STAR-E and HCP to implement this campaign, described the campaign s achievement as follows: With this information we educated communities, involved and trained traditional circumcisers to ensure we all speak from the same page, and people have started realising that there are aspects within the traditional methods that increase the spread of HIV. All hospitals and health centre 4s now have Clinical Officers trained in the medical procedure, though uptake is still relatively low. It takes time. You can t just do away with culture and traditions, but you can try and modify them, and this, I believe, we have achieved. People are starting to realise the risks with the traditional methods and are taking their children to hospital instead, which is definitely a positive trend. The HCP Project Final Report July

38 Supporting People Living with HIV to stay Healthy The Profiling Tool guides us on what specific information can be given in a session, and helps us not to bog down the client with extra information so that then they are unable to understand the specific issues they have come with. It gives us focus It guides the quality. I know it is going to do wonders for us. - Sophie Nantume, TASO

39 Although treatment for HIV is more available in 2012 than a few years ago, as people continue to contract HIV, the need for treatment could outstrip the ability of the Government of Uganda to supply the life saving medication. Therefore, MOH is eager to prevent new infections, promote simple ways that people living with HIV (PLHIV) can live healthier, longer lives without ARVs and encourage early treatment for the most vulnerable. The type of positive living behaviors to communicate varies considerably depending on the age of the audience. Therefore, HCP worked with partners on separate communication and training interventions depending on whether the clients are adults, adolescents or children. Enhancing Positive Living Practices Among Adults Living with HIV While simple proven interventions exist to help PLHIV to stay healthy longer, Uganda lacked national guidelines to define positive living practices in According to results from the 2010 HCP Survey, very few Ugandans were aware of the recommended positive living practices that can help PLHIV stay healthy longer. Finally, MOH, with technical assistance from HCP, coordinated the development the Positive Living Profiling Tool, an innovative tool designed for health care workers and community support agents to make counseling sessions for HIV positive adults on the positive living practices more tailored and effective. Twenty-six MOH national trainers and 13 partners were oriented to the tool. A 17-minute video illustrating how to use the profiling tool was developed for use during the training. Since the campaign to enhance positive living practices among adults living with HIV has only been implemented recently ( ), it is premature to measure the influence this campaign has had on PLHIVs. Since 2011, HCP and other partners have worked under the leadership of MOH to design multi-channel communication aimed at increasing the proportion of people living with HIV who feel confident and adopt positive living practices to stay healthy. The campaign utilized radio diaries of PLHIV, interactive sessions in PLHIV clubs and job aids, client education materials, posters and banners for health facilities. HCP worked closely with PACE, a local civil society partner, and MOH to draft positive living guidelines to be included in MOH s Home Based Care policy. HCP also worked with MOH to produce the positive living radio diaries series, My Life My Story, with eighteen episodes each in 5 languages that were broadcast on 11 national radio stations across the country. The series features a PLHIV for each language program telling their story from the time they learned they were HIV positive, when they disclosed their status to significant others, and how they care for themselves today. Radio diary discussion guides were also developed for use during interactive sessions within PLHIV clubs. Health workers and community support agents were trained to use the discussion guides. The HCP Project Final Report July

40 Voices A Radio Diarist for My Life, My Story : Charles I like to help other people, says Charles, explaining why he agreed to record his story as part of an HCP-supported radio diary program. The idea is that the diarist can help other people through his or her life experiences, and what I really liked about the idea is that it could reach everywhere. I have been volunteering for ten years now, helping a lot of people, but there are places that I can t go. But through the radio, my voice can reach anywhere. It was an opportunity to fulfill what I d been yearning for. Many people don t understand what it is like to live with HIV, but when you express yourself through your own experiences and talk from your heart, then some people can understand better. To me, it is important to help other people not fall in to the same traps as I did. As HIV positive, there are many things that you regret your behaviour, taking life for granted - and you want to bring back what you have lost. This regret can create big problems in your head, so I want to help people to move on from regret, I have to; I don t want anyone to go through what I did. I tested positive in 1995, and back then HIV was a curse, a death sentence. I was scared and in denial so I kept it quiet for three years even from my wife. It affected me a lot, both at home and at work, it was like I had a heat in my heart. So finally I decided to share it with a work colleague, who was like a brother to me. But it was too much for him; he looked at me and saw a moving corpse. I think he was scared as well, because he went straight to my supervisor and told him. That same day I lost my job. I decided that I didn t want to lose my marriage as well, so I still didn t tell my wife. It wasn t until I became very sick and hospitalised that she found out from the doctors while I was unconscious. When she was tested, she too was positive. I never applied for a job again. I was so bitter after being mistreated so badly, having worked so hard for nothing. Instead, I decided to help people like me. I thought, having lived with HIV for 17 years now, there must be a reason why I am still alive and it puts me in a position to help people. Almost everyone reacts the same when they find out they re positive; they think they are going to die. But I am proof that you can live I came back to life! When you re in this situation, it helps so much to talk to other people and to realise that you re not the only one going through this. That is what makes the diary so special. I can record my story and someone out there can listen to it or read it and get something from it, they can feel ok. That is what I am working for. 40 The HCP Project Final Report July

41 Voices Adolescents Share Hope From Jessica and Mike we learnt that, even if you re HIV positive, you can still be useful to the world, just like Jessica who works at the radio station, says Mukisa. That if you take your drugs, you can live a long, good life, and if you remain faithful to your partner you don t spread the virus. Jessica and Mike have given us strength; we re in a healthy situation because of them. I am very proud of the adolescence booklet. I have never seen a product like it before or after, says 23-year-old Gordon Turibamwe, who worked on the Frequently Asked Question adolescent booklet that targets young HIV positives; stories of young people like him are included. Not only are Doreen and Mukisa in a healthy situation, they re also in a happy one. Having met through JCRC, the couple soon got married and now have a 10-month-old daughter, Latisha. Thanks to diligently following the advice by counsellors and health professionals, Latisha was born negative and remains healthy; proof that you can, indeed, be useful to the world and live a good life even if you are HIV positive. I think the reason it works so well is that it was made by real people and based on their real experiences; it isn t just something that someone, somewhere sat down and wrote. We involved young HIV positives from all regions, and I think this involvement was very important. Everybody who reads it has a feeling of attachment to it. When you read it, you know you re not alone. You get hope. Most young positives feel they have nothing to relate to; with the booklet they have. This sentiment is echoed during an adolescent club meeting at JCRC Lubowa. We discuss how to enjoy life, that being HIV positive is not a death sentence, that you can have friends and make a family and have HIV negative children. The booklets are good as they address a lot of the sensitive questions you have as an HIV positive youth that you struggle with every day. Mukisa and Doreen have both been attending their local JCRC adolescent support club for years. The Jessica and Mike comic book and Rock Point 256 storyline has impacted their lives.

42 Improving the uptake of ARVs among children living with HIV In 2010, Uganda had 1.2 million people living with HIV (PLHIV). Of these, 370,000 were in need of antiretroviral treatment (ART) but only 50% of those eligible were accessing treatment. Among children living with HIV (under 15 years), less than 30% were on ART. Without access to ART, 50% of HIV positive children die before reaching the age of two years. Limited knowledge and skills among health personnel to identify and manage children with HIV, and lack of motivation and ignorance about HIV services for children among caregivers of children were identified as key barriers to children accessing treatment. Addressing Challenges Experienced by Adolescents Living with HIV In 2009, HCP worked with Joint Clinical Research Centre (JCRC) to design and implement a primarily interpersonal communication campaign aimed at increasing condom use, disclosure of HIV status with sexual partners, and adherence to ARVs among HIV positive adolescents. HCP produced a comic book and audio summary of a storyline (Jessica & Mike) about a young HIV- discordant couple produced by Y.E.A.H. for Rock Point 256. Among the limited number of young children who are started on HIV treatment in Uganda, evidence shows that as they become adolescents, adherence to treatment becomes a significant challenge. Many adolescents discontinue their ART due to denial or discriminatory and stigmatizing attitudes among their peers. Also, many adolescents and young people who are living with HIV become sexually active without disclosing their status to their partners or using condoms. Many HIV treatment providers and peer HCP worked with JCRC and Y.E.A.H to train peer educators to lead interactive sessions using the Jessica and Mike tools, and to develop additional engaging support materials including a fun interactive game, Make a Positive Start. A frequently asked question book for adolescents living HIV was also developed with significant input from a group of HIV positive adolescents. Working with JCRC and the Uganda Network for Young Positives, HCP supported the implementation of these interactive sessions with adolescents living with HIV in five districts surrounding the JCRC Regional Centres of Excellence. The adolescent campaign increased HIV positive adolescents knowledge about HIV, and positively influenced the lives of adolescents who engaged with the innovative campaign materials. Data from a 2010 study conducted by HCP to evaluate the Make a Positive Start game found that the game contributed significantly to enhancing adolescents knowledge about HIV and attitudes about PLHIV.be useful to 42 The HCP Project Final Report July

43 I was a guest on the Radio One shows. The response we got was overwhelming. We got lots of calls and questions. The hosts were trained so if we forgot something they could guide us. I liked the way that helped the program flow so well. - Goretti Nakabugo, TASO educators lack skills and relevant tools and support materials to communicate about these challenges with HIV positive adolescents. Since 2007, HCP has worked directly with MOH and partners to develop a multimedia campaign to address the low uptake of ARVs among children. The aim was to improve the quality and availability of paediatric HIV services and to encourage and inform caregivers to seek testing and treatment for children at risk of HIV. Two interactive national curricula and 12 accompanying job aids were developed to improve health professionals skills and provide them with the necessary tools and guidelines to effectively counsel, care for and treat HIV infected children and their families. Nationwide, 84 people were trained as master trainers who have now cascaded these two trainings to more than 1,500 health workers and counselors across the country. HCP also supported MOH to work with district level implementing partners to develop and carry out a mix of mobilisation activities at community level, including training community workers and radio hosts to deliver accurate messages on paediatric HIV and providing implementing partners with information and tools to work with health centers and hospitals in their catchment areas to implement paediatric HIV outreach days. A number of health education materials were also developed and distributed including posters, fact sheets for religious, cultural and political leaders, and a music video. The mobilisation activities centered around a radio campaign that broadcast weekly call-in talk shows on paediatric HIV. prescriptions for children. Previously we had to wait and do a lot of consultation, but now with this training, and the job aids that we were given and shown how to use, we are seeing children started on treatment on time and that is reflected in our numbers and that is really quality of care improvements that we are seeing. Since the roll out of the paediatric HIV trainings, we have seen numbers of children started on treatment (ARVs) doubled. Our first partner to roll it out has doubled their enrollment rates of children on ART. Another Partner had 16% of infants on treatment before the Care & Treatment Training, and after the training it increased to 63% on treatment. - Dr. Peter Elyanu, MOH Analyses of service delivery partners performance reporting data revealed significant increases in the number of children accessing HIV services during the community mobilization campaign period as demonstrated on the graph below. Results The number of health facilities offering paediatric HIV services increased from 250 in 2010, before the trainings aimed at improving service delivery were rolled out, to 350 in The quality of the services being offered also improved as one doctor who participated in the paediatric HIV training course reported Our quality of services has improved in terms of the way we make The intensive community mobilisation campaign activities ran from mid - August and to mid - September. The HCP Project Final Report July

44 Voices The Critical Role of Job Aids Training courses in Uganda commonly employ lecture, using copious PowerPoint slide presentations, while more experiential or participatory teaching methods are often less utilized. Guidelines or job aids are often handed out at the end of the training, with little or no reference made to them, and no practice using them. Dr. Peter Elyanu, the ministry official from the AIDS Control Programme involved in the development of both the paediatric HIV care and treatment and the counselling curriculum explains: We learned that a curriculum should be developed around what the health practitioners need to do and use. We learned that our goal needed to be to make sure the modules in the training curriculum were tailored to helping participants use job aids. All the evaluations and feedback we get from our trainers now is that this participatory kind of training that clearly links the teaching with the practical use of the job aids is exactly what is needed. They tell us it is one of the key aspects that makes the positive clinical practices actually happen after the training. Dr. Timothy Nduhukire from Kabale Hospital was a participant in the National Paediatric Care & Treatment Training and explains how the focus on job aids has helped him on the job: After the training I came back more child focused, and now we have these guidelines (job aids) and so we are not doing things by trial-and-error. We are more standardized what I do as a clinician is what other clinicians also do. For example, before we had to pick out the drug treatment insert and try to read through it and figure out the right dose for the child, but now, with the dosing aid we got, if you know the child s weight you can easily use the job aid and be spot on with the correct dose. Ultimately, this reduces the time the child needs to spend in the clinic. So, the aid helps us to do the right thing in the shortest time possible. Sarah Nabirye, paediatric counsellor in Bugiri Hospital and participant in the National Paediatric HIV Counseling Curriculum, explains how the counselling job aids have helped her: It used to be that our paediatric patients never got any special treatment. They were seen with, and treated like, adult patients. There were no special facilities for them and no special knowledge amongst the staff. As a result, the children really got left behind. But after the training, things have really changed. We learned skills and techniques to specifically address the problems HIV positive children experience. Now, there is a special paediatric counselling room with toys and visual aids that help us be at their level. Or by using aids we received, like Lukia Story (a storybook for HIV positive children produced with HCP assistance), we can explain things to children in simple terms, in a way that they can understand. That really helps them realize that they re not the only ones, that they re not alone. One of the master trainers for the counselling curriculum, Goretti Nakabugo, explains: The job aids we use in counseling have improved so much. They are more interactive. We have gotten feedback from TASO clients and they like Lukia s Story and the adolescent book.

45 Reducing the Burden of Malaria and TB The grain sack materials help me explain things better, and helps the client seeing the exact thing. Without images, they often don t understand. They tell me they understand it better with images. - Kaziba Muzamuri, Busesa Health Centre The HCP Project Final Report July

46 Reducing the Burden of Malaria and TB Malaria Communication Malaria is the leading cause of death among children and the most common reason for out-patient visits in Uganda. The National Malaria Control Programme (NMCP) strategy includes intermittent preventive treatment (IPT) during pregnancy, use of insecticide treated nets, treatment of uncomplicated malaria with Artemisinin-based Combination Therapies (ACTs), and indoor residual spraying (IRS) of insecticides in malaria endemic areas. The malaria treatment policy introduced ACTs and the IRS program in 2006, however evidence revealed that one year later, in 2007, information about this policy and program were still not known by most Ugandans. Although the NMCP had introduced IPT during pregnancy in 2001, as of 2007 only 40% of pregnant women took the recommended two doses. To increase Ugandan s knowledge about IPT, in 2007 and 2008, HCP assisted the MOH to produce job aids including a gestational wheel and wall chart for antenatal providers, and to broadcast radio spots, talk shows, and community dramas. Also during this time, HCP assisted the NMCP to produce and disseminate radio spots and brochures about the new treatment policy and its rationale for ACT. HCP also worked with the NMCP and RTI in four districts to increase awareness about and community and household acceptance of IRS through interpersonal, print and electronic communication. This involved production and dissemination of facts sheets for leaders, sprayer pocket reference cards, radio spots, radio talk shows, a video, and community sensitization meetings. HCP assisted NMCP to package all mobilization materials, guidelines and tools as an IRS Community Mobilisation Toolkit, which was launched by the Minister of State for Health in 2008, and used during subsequent IRS exercises. Results An evaluation of malaria job aids conducted by HCP in 2008 found that the job aids produced to support IPT counselling, particularly the gestation wheel, were regularly used among antenatal providers, and were useful in determining estimated date of delivery, when to administer IPT and folic acid, and to counsel about PMTCT. Results from the 2008 HCP/Y.E.A.H. Survey showed that 91% of men and women had heard a message about IPT in the previous 12 months, and 46 The HCP Project Final Report July

47 those who had heard IPT messages were significantly more likely than those who had not to say they intended to take two doses of IPT during their next pregnancy. In the four districts where awareness raising activities about IRS were carried out, approximately 98% of households allowed the sprayers to spray their homes, and prepared their homes for the spraying effort. In one district where IRS took place, almost all respondents (94-97%) could recall the main messages in the IRS communication effort. Almost all respondents got the message to remove all portable household items including food, before the spray exercise (94%); and after the spraying exercise, to remain outside for 2 hours (97%). The same study revealed that 49% of men and women had seen or heard messages about the new treatment policy (ACT), and increased frequency of exposure to messages was associated with an 88% increase in the probability of an individual having used ACTs in the last 6 months; 126% increase in the probability of agreeing that ACTs are more effective in curing malaria compared to Chloroquine and Fansidar; and 158% increase in the probability of encouraging someone else to use ACTs. TB/HIV Communication Uganda is ranked 16 th among the 22 high burden Tuberculosis (TB) countries in the world, with approximately 70,000 80,000 new TB cases detected in the country every year. Despite efforts to control TB, Uganda is yet to attain the global case detection and treatment success targets of 70% and 85% respectively. Whereas TB presents a public health problem in itself, the interaction between TB and HIV aggravates the situation. Studies show that 50% of TB patients are co-infected with HIV. Though curable, TB is still one of the major causes of sickness and death among people living with HIV. A December, 2007, study conducted by the Ministry of Health, WHO and the International Union Against Tuberculosis and Lung Diseases, on barriers to the implementation of TB/HIV collaborative activities in Uganda noted that, although the National TB/ HIV Policy Guidelines and Communication Strategy were launched in March 2006, only 10% of health workers and 17% of community resource persons were aware of them. Lack of knowledge was a major barrier to provision and utilization of TB services by PLHIV and HIV services by TB clients. Over a one-year period in 2007/8, HCP provided assistance in the area of health communication to the National TB and Leprosy Program (NTLP), the Tuberculosis Control The HCP Project Final Report July

48 Assistance Program (TBCAP), NUMAT and WHO. HCP worked as a member of the team to design a Message and Media Plan to operationalize the National TB/HIV Communication Strategy. Following this plan, HCP assisted NTLP and its partners to design a national TB logo and signage to identify TB screening and treatment services as well as job aids and client education materials for TB clients, HIV clients, and community members, including a counseling flip chart, a community grain sack chart set for community resource persons, and posters for health facilities and communities. HCP also assisted the NTLP to produced and disseminate the TB/HIV Collaboration Guidelines and the National TB/HIV Communication Strategy to district leaders and health facilities in 66 districts; and to map and prepare a directory of TB and HIV services in Uganda, which was distributed to all health facilities in 66 districts. Approximately 200 health centers offering TB and HIV services were branded with the yellow TB sign. Since most health communication can only be influential by linking clients to services, one of the key approaches that HCP with the MOH took was developing logos for each program. The logos were then put onto sign posts that implementing partners installed at relevant health facilities. Within radio programmes and through community drama, the characters would model the desired behaviour of clients identifying the services by the sign with the logo. In addition to marking the services, HCP worked with the MOH to ensure that the location of specific services was mapped in order to create directories. The directories were distributed to health service sites as well as to the National Health Hotline. Health workers and hotline counsellors were then in the position to provide better referrals. 48 The HCP Project Final Report July

49 Strengthening Health Communication Capacity HCP has involved marketing people, radio journalists, creative artists, designers, etc. Before we had to wait for a doctor to talk about the issue, now we have many others and community mobilizers talking about key health issues. This helps to build infrastructure. - Richard Kintu, World Vision The HCP Project Final Report July

50 Capacity Strengthening in SBCC When HCP began in 2007, it conducted collaborative capacity assessments among some of its partners and its staff to identify areas for improvement. While most of the individuals and organizations were aware of the SBCC process, they were not following it well, and very few were familiar with behavior change theories or how to apply them to strategy design. In addition, there were very few creative designers capable of designing print materials, dramas, or other materials based on a SBCC strategy. Throughout its five years, HCP offered capacity strengthening opportunities for staff and partners, including radio scriptwriters and directors, creative directors, copywriters, and health communication staff from district-based and USG supported implementing partners. Specifically, HCP provided training in scriptwriting for radio drama, orientation of advertising agency staff and SBCC professionals on creative concept development and testing, short courses on basic SBCC processes and principals, training on directing radio dramas, management training, and orientation to data interpretation and application. HCP also assisted the MOH and other SBCC partners to hold quarterly meetings to promote coordination and sharing of lessons learned and promising practices. Our team benefits by gaining a good understanding of the process rather than just using the materials without being part of the process. - Dr. Edward Bitarakwate, STAR-SW HCP has been very helpful in organising these meetings enabling BCC people coming together. We need to make sure we sustain these meetings after HCP finishes. We appreciate what HCP has done; they have been a true partner, consulting and sharing throughout. We have enjoyed working with them. - Dr. Paul Kagwa, MOH Results 50 staff from implementing partners trained in strategic health communication. 15 quarterly BCC partners meetings 30 staff from all major advertising agencies in Uganda trained in SBCC concepts and materials Over 20 Ugandan scriptwriters, directors and producers trained. 50 The HCP Project Final Report July

51 Voices UHCA Makes a Big Leap There is a lot of hunger in the health movement and among health organizations to connect with journalists, and HCP is one of those, so there was a natural bond between HCP and us, said Richard Baguma, Coordinator for the Uganda Health Communication Alliance (UHCA). UHCA is a professional organization that brings together journalists and other communication professionals from non-government organizations, government and academia. Their aim is to improve the quality of health information available to Ugandans. Since 2009 HCP has supported UHCA to develop training materials and carry out trainings for journalists on various health issues. Richard Baguma describes UHCA as a kind of baby that is trying to leap. He claims that in a relatively short period of time UHCA went from being merely a group of journalists who were working in an unstructured manner to a well-respected organization that journalists and organizations now look to as a leader in bridging the gap between health workers and journalists. We had no knowledge or background in curriculum development so we thought of a module as a PowerPoint presentation. Then we had an orientation with HCP to think about what materials we need, how much time we need, and things like that. And we shared with them (HCP) how media houses work. And through this kind of process, together we developed the Media House Training Program that all our partners are now using. We (journalists) are like an army with poor training, and the health movement does not clearly see the link of journalism and health. HCP recognized that we, even senior journalists, don t have the skills to be trainers or develop curricula on our own, and so they provided us with resource persons as trainers, and also gave us basic training on training adults and experiential learning. These TOTs were very valuable to us. The curriculum and training skills we gained we will retain. We are not experts in curriculum development but we can at least critique curricula and materials and that is a useful foundation. As a mutually supportive partner, HCP helped UHCA to raise its profile as an organization. According to Baguma, HCP was quite successful in this effort and UHCA has benefitted greatly: HCP is present in many health forums and they have been a sort of public relations for us and this has been very helpful for us. They have suggested to other partners to seek our services. We now feel more confident the profile that HCP has helped us to build is very strong and we would really have to mess up lots to not continue with other partners. Journalists and other organizations now trust us and are aware that we have something to offer them. And now we are getting many requests from health organizations to interface with journalists. And we know that partnerships will grow out of these people seeking our help.

52 Influencing the Media for Health Promotion The media plays a vital role in setting the agenda for what people talk about and are agents of change. Yet few development and health organisations have strategically worked with the media for health promotion. Before initiating the media relations initiative, HCP and the UHCA noted that the quantity and quality of media coverage on health issues was quite poor and there were many inaccuracies in content. Stories on family planning, male circumcision, HIV, and maternal and child health were at times misleading and did not reflect relevant MOH policies and strategies. Journalists were simply not conversant with health issues and they did not have the time and skills to analyse highly technical health content to turn it into human-interest stories for media consumption. HCP worked with the UHCA, a newly created association of veteran and practicing health journalists, to improve the quality of reporting on health issues in the print and electronic media. The first step was to conduct a content analysis of media programming on health. HCP conducted visits to radio, TV, and print media houses across the country, and held in-depth discussions with staff to understand their needs and how they operate. HCP and UHCA then worked together to develop ten short media house training modules on health reporting, family planning, population and development, SMC, CHCT, stigma reduction, HIV care and treatment, alcohol abuse, and gender based violence. HCP conducted a short training course for the UHCA journalists in adult learning and facilitation skills, and contracted UHCA to conduct short one two hour training sessions in media houses outside Kampala. In total, UHCA conducted training for 50 media houses and 400 journalists, including reporters, talk show hosts, DJs and station managers. Many were trained in more than one health issue. Through this effort, HCP and UHCA established a network of 400 health journalists, many from rural radio stations. Through this network, most of whom have addresses, HCP was able to disseminate press releases, fact sheets, and announcements about training opportunities. Results Some talk show hosts and managers of radio stations provided free airtime for topics covered during the training. This included 12 free talk shows on SMC, six on family planning, four on pediatric HIV, and three on CHCT. Because UHCA usually conducted media house training together with district health officials or health workers, the media representatives made connections with local health experts to host during programs on their stations. After the trainings, some journalists developed new programs on health issues covered during the training. 52 The HCP Project Final Report July

53 Voices Story of Lydia Apicha, Radio Presenter Lydia Apicha has been a radio presenter specializing in health programs for over 10 years. Lydia is one of the 400 journalists trained in health reporting across Uganda by UHCA. At Open Gate radio in the eastern district of Mbale, Lydia is in charge of all health programs and presents a two-hour health show every Tuesday. Although she is considerably informed on matters concerning health, Lydia counts herself lucky to have been trained on health reporting by UHCA and HCP: I feel more knowledgeable and more confident to answer questions on topics which I was trained on, she says. To test this new knowledge, Lydia did three shows on paediatric HIV and another three on family planning. She commented on the shows addressing pediatric HIV, the response was good and people were surprised that the number of children infected with the HIV virus was increasing. The audience thought that HIV in children was a new kind of disease. Although the pediatric HIV radio campaign was designed to have technical guest speakers on the show with the radio host, Lydia notes that at times her scheduled guests did not turn up and so she had to answer the questions from the callers on her own. However, Lydia says she was confident to speak on the topics she was trained on and that the written information on each topic provided to her served as a very useful guide. She also proudly noted, there are so many issues affecting children and adolescents infected with HIV. And I learnt how to handle children infected and affected by HIV. Much as Lydia is grateful for the training opportunity, she said there was still need for more comprehensive training for all journalists in the country on health issues like cancer, family planning misconceptions, and more importantly HIV discordance among couples, as this last issue is a source of violence among families.

54 Mentoring Young Professionals In Uganda, most university graduates leave school with very little professional and career guidance. Very rarely are prospective graduates queried about their professional aspirations. Many have no idea how to write a CV or conduct a professional job interview. As a result, Uganda has one of the highest youth unemployment rates in the region, and still lacks much needed local experts in all major development sectors. Skilled graduates in communication, economics, agriculture, oil and gas, communications, public health, marketing and human resource, among others are needed in private and public organizations to propel Uganda to the next level. Recognising this need to provide graduates with opportunities to acquire job-related skills, HCP established the Generating Opportunities for Leadership and professional Development (GOLD) internship program in GOLD is a one-year mentoring and career guidance program for young Uganda graduates interested in a carreer in health communication. Following a competitive process, GOLD selects young people and identifies suitable placements for them in organizations that match their career aspirations. Young professionals are assigned to organizations, given scopes of work, and dedicated supervisors and mentors. They also attend 12 monthly professional development seminars during the course of their internship. Results The program has been supported by many public and private sector partners. More than 30 organizations have hosted GOLD members, and more than 50 professionals, who work in a variety of sectors, have served as mentors and supervisors to these young professionals. To date, 200 young professionals have graduated from the program, and the majority of them are gainfully employed, while a few have decided to pursue further studies. A high demand among graduates for the few available places in the program indicates the great need and desire for such a program. Fortunately the value of such a capacity building program has been recognized, and so GOLD will continue to operate and will expand with assistance from the Private Sector Foundation Uganda (PSFU). PSFU plans to scale-up the program by increasing the number of graduates it accepts and places in organizations for internships each year. 54 The HCP Project Final Report July

55 Voices I m a proud GOLD pioneer. I m a proud GOLD pioneer, says Duncan Musumba, who was in the first class of GOLD interns to graduate in The internship was a 1-year programme following university. We did a series of seminars and met once a month to learn practical skills such as professional behaviour and CV writing and attended motivational lectures from Human Resources staff from various partner organizations. It was great because these were all things we didn t learn at university, and it really helped me discover my strengths and realize where I wanted to go. My internship was with UHMG in the communications department. After that first year they hired me as a Product Marketing Officer and I was later promoted to BCC Officer. The GOLD programme really is just that gold! A golden opportunity for youth such as myself to come face to face with real life and a real work environment. To learn how to use your knowledge in a practical sense, and to realize that your journey has just started. I honestly think the Government should make such initiatives national policy. It would help young people such as myself a great deal in getting their careers going. You get experience and contacts, and you build your confidence, which in turn helps you when you start interviewing for jobs. After four years with UHMG I got a job with Marie Stopes Uganda as Integrated Marketing and BCC Manager, where I m responsible for developing marketing and communications strategies, making sure BCC is integrated properly throughout. It s a great job, and one that I would never have landed without the experience and confidence I gained from the GOLD programme. It all goes back to that! Mr. Gideon Badagawa, Executive Director of the PSFU expresses a similar sentiment, GOLD in itself is golden because it creates opportunities and therefore it will reduce unemployment in the country. Although it started with only 10 trainees in 2008, in total 135 graduates have benefitted from placements in 32 companies and organizations. Over the last four years, 87% of the graduates of the program were hired by their host organizations.

56 Conclusion and Recommendations Communication is not cheap and simple it is not just running articles or radio announcements or looking at a poster that is where HCP found us. And they have helped to show us that communication can be done well. how it can help to influence policy, how we can develop materials that cause further thinking - Dr. Akol Zainab, MOH

57 HCP has been at the forefront of streamlining materials. When HCP is gone, we need to keep that practice and continue to go through MOH, as they have taught us to do. - Dr. Raymond Byaruhanga, AIDS Information Centre This end of project report aims to demonstrate how HCP made a difference in the lives of people across Uganda. The approach that HCP utilised to meet the goals of the project proved to be effective, especially using the systematic process outlined in the P-process: analysis; strategic design; development and testing; implementation and monitoring; and evaluation and replanning. Since a critical component of the P-process is participation, throughout this end of project booklet are the voices of partners and beneficiaries who explain how they have participated in the process: from HIV positive adolescents participating in the development of a booklet to help other young people living with HIV manage stigma and adherence; to involving nurses, clinical officers and other health professionals in the development of job aids; to ministry officials gaining the experience and confidence to know which questions to ask and how to lead communication activities. Below are the top ten recommendations that HCP can share based on seven years of working with the MOH, UAC and their partners. These are based on lessons learnt throughout the project. Some of them we implemented from the beginning and some of them we had to learn while in action. Either way, sharing these recommendations is an important last step in the health communication collaboration. 1. Continue Implementing Campaigns and Using Materials HCP assisted the Government of Uganda to design health communication strategies, materials and campaigns from situation analyses, formative research, materials development and testing, to implementation and monitoring. Some communication materials were only released in the last months of HCP and should be used more widely. All of the strategies, materials and tools that you need are available on: 2. Develop Collaborative Partnerships by Being Inclusive and Flexible One of the most important partners for health communication is the MOH and its technical working groups. The members of these groups represent the majority of partners assisting with the implementation of health services and are experts in their field. Involving these groups helps ensure accuracy, relevance and ownership. One of the best ways of being inclusive is to avoid branding communication materials with logos from development partners, projects, and civil society organizations. The materials that HCP produced with the MOH were used by partners because they carried only the MOH brand, which encouraged an environment of joint ownership. Normally, partners want their logos on materials at times you would end up with 30 logos on one poster. The logos would be more visible than the message. We discussed this with HCP and agreed it was an unhealthy approach, so to support the Government of Uganda we decided only to feature the MoH logo. This also ensured that the materials would have a longer shelf life. - Dr. Paul Kagwa, MOH Actively involving other partners such as political, faith-based and cultural leaders as well as the media greatly improves the reach and effectiveness of health communication. Without engagement they can be very powerful road blocks. 3. Strengthen Research, Monitoring and Evaluation of SBCC Most SBCC interventions in Uganda have not been properly evaluated to know what works and does not. The pending USAID Joint BCC Survey is a step in that direction and should be repeated on an annual or biannual basis. Partners that implement communication strategies should provide regular monitoring data so the MOH knows where campaign activities are taking place and The HCP Project Final Report July

58 whether or not they are associated with changes in service delivery data. SBCC organizations should plan to provide supportive supervision of communication interventions, as an excellent means to trouble shoot and get feedback. 4. Faithfully follow the communication process Effective communication follows the five-step process of analysis, design, development and testing, implementation and monitoring, and evaluation and re-planning. Throughout the process, successful communicators encourage participation at all levels from national working groups to involvement of the audience in design, implementation, monitoring and evaluation. Successful communication strategies build the capacity of communities and individuals as well as stakeholders at national and district levels. 5. Plan for Longer-term Implementation of Communication Strategies It takes from six to nine months to design an effective communication strategy, and another three months to develop and test materials. Implementation generally involves orienting district -based partners and community resource persons, as well as dissemination of print and electronic media materials. Once community resource persons and service providers have embraced a new campaign, they should be encouraged to continue communicating about that issue for at least a year before re-orienting them to a new campaign. HCP s recommendation is that communication programs should schedule at least a two year cycle between design and re-design. 6. Link Training to Job Aids Job aids help remind health workers or community resource persons how to do their jobs after training. But, the job aids will not be used if health workers are not trained to use them. Include orientation to job aids in training curricula, and provide opportunities for practical exercises to increase the likelihood that they will use them on the job. 7. Prepare outlines for radio and television talk shows Before organizing radio or television talk shows, take time to outline the content of each program. Outlines should identify the specific objectives of the program, and should include adequate background information on the issue for presenters. They should also include questions and answers that the presenter and guest can discuss while waiting for listeners to call in. HCP found that radio presenters were far more likely to independently organize talk shows about issues when they had written outlines. 8. Link Communication Efforts to Health Services During the analysis step of the communication process, identify where services are available so that you can direct people to them. If services are few and far between, do not broadcast demand creation messages to areas where there are no services. Instead, identify communication channels that will reach the widest audience possible within the catchment areas of available services. To facilitate referrals for services, it is critical to share a list of services with health workers, leaders, hotlines and media houses. 9. Promote Professional Development for SBCC professionals Since there is no pre-service professional training in SBCC in Uganda, most professionals learn on the job. Opportunities for training and mentoring in SBCC are sporadic at best. A step in the right direction is to continue the quarterly BCC meetings, and through these, share opportunities for training and mentorship as they arise. 10. Support the Sustainable Activities Initiated with HCP Support The National Health Hotline and Radio Distance Learning Programme are excellent means of providing health information and referrals for services. Please work with CDFU and World Vision Uganda to support these initiatives. The GOLD internship programme has created new opportunities for young people, and now that PSFU is taking over its management, please continue to host GOLD interns in your organizations. 58 The HCP Project Final Report July

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